Last updated: June 29th, 2020 at 07:41 pm
PRE-TREATMENT-SCREENING CHECK (COVID-19) Pre-screening is now a public health recommendation for patients prior to attending for treatment. This measure is an effort to minimise the risk of the spread of COVID-19 within our communities. Pre-screening should be completed prior to a patient attending the clinic as a risk management protocol.
COVID-19: In compliance with Health & Safety Guidelines, it is clinic policy that precautionary measures are taken to prevent “close contact” during your visit with us.
“Close contact” as defined by the HSE is: “any individual who has had greater than 15 minutes face to face within 2 metres contact in any setting”. We avoid this by doing the following:
The acupuncturist wears PPE (face mask & gloves). The distance of 2 metres is maintained at all times during your visit (except when inserting/removing needles, which is a combined total of less than 15 minutes).
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PRE-TREATMENT-SCREENING QUESTIONS: circle Yes or No
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YES | NO | |
Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days? |
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NO | |
Have you been in close contact with a confirmed or suspected case of COVID-19 in the last 14 days? (i.e. less than 2m for more than 15mins accumulative in 1 day). |
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NO | |
Do you have symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness or flu like symptoms now or in the past 14 days? |
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NO | |
Have you been advised by a Doctor or the HSE to self-isolate at this time?
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NO | |
Have you been advised by a Doctor or the HSE to cocoon at this time?
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NO | |
Have you travelled outside the country in the last 14 days |
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NO |
I understand that this information is required for the purposes of public health & will be kept on file for a 2 month period from the date of signing. I confirm that the above information is true & accurate from the date of signing. I understand that my personal information including my name & contact details may be shared with the Health Service Executive(HSE) for the sole purpose of contact tracing in line with public health guidelines only if requested.
I verify that the acupuncturist is/was wearing PPE (face mask & gloves) & the precautions to prevent “close contact” listed on above are in place & adhered to.
Signature ____________________________________ Date: ___/___/_____